Information Technology Implementation by Cognitive Engineering of Organizational Routines (Michigan)

Project Final Report (PDF, 828.05 KB) Disclaimer

Project Details - Ended

Project Categories

Summary:

Successful implementation of clinical quality management systems (CQMS) is challenging in primary care. At a minimum, it requires that practices adapt their clinical workflow and potentially their organizational routines. This project identified three rural Federally Qualified Health Centers (FQHCs) to implement Crimson Care Registry, a commercial CQMS that includes: 1) a disease registry, 2) point-of‐care clinical reminder system for both preventive and chronic disease management, 3) call lists and automatically generated letters for patient reminders, and 4) detailed reports for administrative and quality improvement purposes.

Following an iterative process, Crimson Care was tailored to the quality improvement priorities at each FQHC. Cognitive task analysis (CTA) was used to examine the change process needed for successful adoption of the CQMS. CTA is a set of highly structured and complementary qualitative methods to understand work patterns and decisionmaking in real world environments. The findings from CTA were then used to guide interventions to improve the implementation process.

The specific aims of this project were as follows:

  • Identify the barriers and facilitators to implementing CQMSs in safety-net ambulatory care settings. 
  • Measure the impact of using cognitive engineering tools during implementation of a CQMS. 

CTA identified key features of organizational routines that influenced the success of adopting the CQMS. The first FQHC had significant planning and coordination deficiencies. The recommendations for addressing them were not adopted, and the implementation ultimately failed. The practice administrators at the second FQHC were skilled with planning and they followed the recommendations in their CTA report; however, the FQHC closed for unrelated reasons and adoption of the system was not achieved. The third FQHC had good coordination, but limited planning and monitoring skills. This FQHC followed the CTA report recommendations to improve its planning and monitoring processes, and ultimately overcame technical barriers to successfully implement the system.

This project demonstrated that CTA was effective in a primary care setting for identifying deficits in the implementation of a CQMS and that a guided intervention can improve system adoption.

Information Technology Implementation by Cognitive Engineering of Organizational Routines - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018170
  • Project Period: 
    December 2009 – July 2013
  • AHRQ Funding Amount: 
    $1,199,139
  • PDF Version: 
    (PDF, 272.76 KB)

Summary: Successful implementation of health information technology (IT) systems requires substantial attention to workflow processes. This project examines the change that must occur for successful adoption of health IT and how to best reengineer workflows. The Department of Family Medicine at the University of Michigan and the Michigan Primary Care Association have identified three federally qualified health centers (FQHCs) to implement Crimson Care Registry (formerly known as Cielo ClinicTM), a commercial clinical quality management system developed by family medicine physicians at the University of Michigan. The use of Crimson Care is being tailored to each participating FQHC’s interest and priorities. Each clinic is using an iterative process to choose the screening, prevention, chronic disease management, and outreach components of the Crimson Care software that fit their quality improvement priorities best.

Dr. Green and his research team are examining the change process needed for successful adoption of the quality management system by using an advanced set of tools as part of cognitive task analysis (CTA) to guide the implementation and reengineering work. Each practice has an existing electronic health record (EHR), but EHR functional component use varies. Implementation focuses on training site staff to work in teams to understand and modify organizational routines using Crimson Care. Clinics are working on implementation until they achieve success, or until several plan-do-study-act (PDSA) cycles without progress make it clear that implementation will not succeed. Practices have been evaluated to determine whether the Crimson Care clinical system increases adherence to evidence-based practice and whether CTA-guided implementation is advantageous to the health centers. The study is using a mixed-methods, stepped-wedge research and evaluation design to allow analysis of data across time within sites and to make across-site comparisons. The project collected qualitative data on the implementation process, including the barriers and facilitators encountered, which will help health care leaders implement new technology in ambulatory safety-net settings.

Specific Aims:

  • Identify the barriers and facilitators to implementing clinical quality management systems in safety-net ambulatory care settings. (Ongoing)
  • Measure the impact of using cognitive engineering tools during implementation of a clinical quality management system (Crimson Care – formerly Cielo Clinic™). (Ongoing)

2012 Activities: By design, each of the three clinical sites implementing Crimson Care Registry is in a different stage of the implementation process so that lessons learned can be applied successively across the sites. The first site installed the Crimson Care software and participated in onsite meetings with the research team. After implementing and operating the software for 3 months, the center decided to cease implementation of Crimson Care for reasons that were foreseen in the CTA and addressed but not acted upon in the project’s recommendations. In 2012, the research team was able to analyze the full transcription of interviews from these site visits to produce rich qualitative data to describe the factors that resulted in halted implementation.

The second site had continued difficulty in installation of Crimson Care due to the data being installed on the wrong server and a delay in identifying this problem. Although this was corrected, it slowed implementation for this site by a few months. Later in 2012, this same site had difficulty loading data from Patient Electronic Care System (PECS), their prior registry system, into Crimson. This was ultimately resolved by Dr. Green writing code to facilitate the data transfer, but it further slowed implementation of the Crimson software.

The third site launched Crimson Care in the summer of 2012 and has had several months of successful implementation. This practice has been participating in onsite meetings and responding to feedback to guide implementation, such as creating a leadership plan. They have conducted several cycles of PDSA since implementation. After launch of the software the research team conducted a site visit to shadow particular staff, understand their roles, and glean information on their use of the Crimson Care. In addition, they reviewed the patient encounter form and reporting process. Data gathered from the third site followup visit will be analyzed and the research team will present CTA interview findings to leadership in 2013.

A 1-year no-cost extension was used to extend the time frame for software implementation and data collection on the implementation process of Crimson Care. As last self-reported in the AHRQ Research Reporting System, project progress is mostly on track and the project budget funds are somewhat underspent. The implementation process of Crimson Care has been delayed at the remaining two clinical sites for various reasons, and this has delayed some spending of the budget. Dr. Green is working with each site to overcome their implementation challenges and, as part of the research process, is documenting those challenges and what is learned.

Preliminary Impact and Findings: The results of CTA interviews were presented to the clinic leadership. The analysis discovered areas of reliance on tacit knowledge that have potential implications for implementing health IT. For example, CTA revealed differing assumptions and expectations among providers who believed they were in agreement about guideline implementation. As the implementation process has progressed and challenges have arisen, the research team identified the need for a liaison between the health centers and the software vendor to ensure issues are resolved in a timely manner. Health center staff may not have the resources or experience to resolve software installation problems with vendors.

The research team completed “Cognitive Task Analysis: methods to improve the patient centered medical home, by understanding and leveraging its knowledge work,” (PDF, 2.02 MB) (AHRQ Publication Number 13-0023-EF), a monograph on the implications of their results on medical home transformation. The research team plans to write several papers describing the implementation of health IT in safety-net provider organizations. A specific component of the discussion will be the implementation of health IT by a safety-net provider in comparison to an organization that has the resources for in-house consultants and Lean process-thinking coaches. Other paper topics include description of the change management process and methodological approach  of the research team.

Target Population: Medically Underserved, Safety Net, Uninsured

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Information Technology Implementation by Cognitive Engineering of Organizational Routines - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018170
  • Project Period: 
    December 2009 - November 2012
  • AHRQ Funding Amount: 
    $1,199,139
  • PDF Version: 
    (PDF, 191.82 KB)

Summary: Successful implementation of health information technology (IT) systems requires substantial attention to workflow processes. This project examines the change process that must occur for successful adoption of health IT and how to best reengineer workflows. The Department of Family Medicine at the University of Michigan and the Michigan Primary Care Association have identified three Federally-Qualified Health Centers (FQHCs) to implement Cielo Clinic TM , a commercial clinical quality management system developed by family medicine physicians at the University of Michigan. The use of the Cielo Clinic TM is being tailored to each participating FQHC's interest and priorities. Through an iterative process, each clinic is choosing the screening, prevention, chronic disease management, and outreach components of the Cielo Clinic TM software that best fit their quality improvement priorities.

This project examines the change process needed for successful adoption of the quality management system using an advanced set of tools as part of cognitive task analysis to guide the implementation and reengineering work. Each practice included has an existing electronic health record (EHR), but EHR functional component use varies. Implementation focuses on training site staff to work in teams to understand and modify organizational routines using the Cielo Clinic TM . Clinics are working on implementation until they achieve success, or until several plan-do-study-act cycles without progress make it clear that implementation will not succeed. Practices will be evaluated to determine whether the Cielo Clinic TM clinical system increases adherence to evidence-based practice and whether cognitive task analysis-guided implementation is advantageous to the health centers. The study is using a mixed-methods, stepped-wedge research and evaluation design to allow analysis of data across time within sites and to make across-site comparisons. The project will collect qualitative data on the implementation process, including the barriers and facilitators encountered, which will help health care leaders implement new technology in ambulatory safety net settings.

Specific Aims:

  • Identify the barriers and facilitators to implementing clinical quality management systems in safety net ambulatory care settings. (Ongoing)
  • Measure the impact of using cognitive engineering tools during implementation of a clinical quality management system (Cielo Clinic TM ). (Upcoming)

2011 Activities: Each of the three clinical sites implementing Cielo Clinic TM is in a different stage of the process. The first site has installed the Cielo Clinic TM software and the research team is currently analyzing transcripts from their site visits. They are doing full transcription of the interviews to produce rich qualitative data. The second site plans to go live with the Cielo Clinic TM software early in 2012. Once the implementation date is scheduled, the research team will visit the clinic. The third site is about to begin and the project team is scheduling their first meeting with them for early 2012. The third site is unique because before participating in this research grant they attempted to implement Cielo Clinic TM and failed. The research team will help them work through the failure points in the previous implementation process.

As last self-reported in the AHRQ Research Reporting System, project progress is mostly on track and the project budget funds are significantly underspent. The implementation process of Cielo Clinic TM has been delayed at all three clinical sites for various reasons. The principal investigator is working with each site to overcome these challenges and is documenting these challenges as part of the research process.

Preliminary Impact and Findings: The results of cognitive task analysis interviews were presented to the clinic leadership. The cognitive task analysis discovered areas of reliance on tacit knowledge that have potential for significant implications for implementing health IT. For example, the cognitive task analysis revealed differing assumptions and expectations among providers who believed they were in agreement about guideline implementation.

The research team plans to write several papers describing the safety net environment for health IT. One specific component of the discussion will be the implementation of health IT by a safety net provider in comparison to an organization that has money for in-house consultants and Lean process thinking coaches. Other paper topics include description of the change management process and methodological approach of the research team.

Target Population: Medically Underserved, Safety Net, Uninsured

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Information Technology Implementation by Cognitive Engineering of Organizational Routines - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    RFA: HS08-270: Utilizing Health IT to Improve Health Care Quality Grant (R18)
  • Grant Number: 
    R18 HS 018170
  • Project Period: 
    December 2009 – November 2012
  • AHRQ Funding Amount: 
    $1,199,139
  • PDF Version: 
    (PDF, 367.7 KB)


Target Population: Medically Underserved, Safety Net, Uninsured

Summary: Successful implementation of health information technology (IT) systems requires substantial attention to work flow processes. This project closely examines the change process that must occur for successful adoption of health IT and how to best reengineer workflows. The Department of Family Medicine at the University of Michigan is partnering with the Michigan Primary Care Association to identify three Federally Qualified Health Centers (FQHCs) to implement Cielo Clinic™, a commercial clinical quality management system developed by family medicine physicians at the University of Michigan. The use of the Cielo Clinic™ will be tailored to each participating FQHC’s interest and priorities. Through an iterative process, each clinic will choose the screening, prevention, chronic disease management, and outreach components of the Cielo Clinic™ software that best fit their quality improvement priorities.

This project closely examines the change process that must occur for successful adoption of the quality management system using an advanced set of tools called cognitive task analysis to guide the implementation and reengineering work. Each practice included has an existing electronic health record (EHR), and practices vary in their use of different functional components of their EHR. Implementation will focus on training the site staff to work as teams in understanding and modifying organizational routines using the Cielo Clinic™. Clinics will work iteratively on implementation until they achieve success, or until several Plan-Do-Study-Act cycles without progress make it clear that implementation will not succeed. Practices will be evaluated to determine whether the Cielo Clinic™ clinical system increases adherence to evidence-based practice and whether cognitive task analysis-guided implementation is advantageous to the health centers. The study will use a mixed-methods stepped-wedge research and evaluation design to allow analysis of data across time within sites and to make across-site comparisons. The project will collect qualitative data on the implementation process, including the barriers and facilitators encountered, which will provide information to health care leaders on how to best implement new technology in the ambulatory safety net environment.

Specific Aims:
  • Identify the barriers and facilitators to implementing clinical quality management systems in safety net ambulatory care settings.(Ongoing)
  • Measure the impact of using cognitive engineering tools during implementation of a clinical quality management system (Cielo Clinic™).(Upcoming)

2010 Activities: Two of the three planned FQHCs began their planned project activities in 2010. The project team completed cognitive task analysis interviews at each of these health centers with the goals of understanding organizational operations such as roles and responsibilities, current communication mechanisms, and areas of comfort and discomfort with organizational change. This information was used by the research team to develop an initial map of the health center’s current organizational routines that may be affected by implementation of Cielo Clinic™. At both of these sites, Cielo Clinic™ was installed. Further, the research team began to work with each clinic to identify the priority areas for quality improvement and the quality metrics they may use to measure progress. The third clinic slated for implementation of the Cielo Clinic™ and cognitive task analysis was in the final stages of review and identification at the conclusion of 2010 and will begin implementation in 2011.

Grantee's Most Recent Self-Reported Quarterly Status (as of December 2010): The project team is on track with all project milestones, and the budget spending is on target.

Preliminary Impact and Findings: The results of cognitive task analysis interviews were presented to the clinic leadership. The process of cognitive task analysis was successful in discovering areas of reliance on tacit knowledge that have potential for significant implications for implementing health IT. For example, the cognitive task analysis revealed differing assumptions and expectations among providers who believed they were in agreement about guideline implementation.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Information Technology Implementation by Cognitive Engineering of Organizational Routines - Final Report

Citation:
Green L. Information Technology Implementation by Cognitive Engineering of Organizational Routines - Final Report. (Prepared by the University of Michigan under Grant No. R18 HS018170). Rockville, MD: Agency for Healthcare Research and Quality, 2014. (PDF, 828.05 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
Principal Investigator: 
Document Type: 
Medical Condition: 
This project does not have any related resource.
This project does not have any related survey.
This project does not have any related project spotlight.
This project does not have any related survey.
This project does not have any related story.
This project does not have any related emerging lesson.